Wealth Disparities in Obstetric Surgery for Absolute Maternal Indications in Ghana
A major challenge of measuring the unmet need for obstetric surgeries, including caesareans, is determining the need for such operations. Absolute maternal indications (AMIs) are complications for which the mother is very likely to die without surgery, thought to occur in 2% of deliveries. Obstetric surgeries for AMIs below this 2% threshold has been suggested as an indicator of unmet need for life-saving obstetric surgery. Our objective was to determine whether the proportion of deliveries with surgery for AMIs varies according to wealth.
METHODS:
We performed a secondary analysis of the ObaapaVitA trial of vitamin A supplementation, including its population surveillance data, in central Ghana. Data from facility records were used to identify obstetric surgeries for AMIs in hospitals performing surgery. The proportion of all deliveries receiving surgery for AMIs was calculated for each quintile separately.
RESULTS:
Our sample consisted of 50,274 deliveries between June 2005 and October 2008, 41% of which occurred at home. The proportion of hospital deliveries with an AMI decreased with increasing wealth, from 8% in the poorest quintile to 5% in the richest quintile. Conversely, the proportion of all deliveries receiving surgery for an AMI increased with each additional quintile of wealth, from 0.84% in the poorest quintile to 2.64% in the richest. These findings were robust to using a broader definition of AMIs. All but the highest quintiles were below the 2% threshold.
CONCLUSIONS:
Our findings suggest that there is an unmet need for life-saving obstetric surgery in all but the richest quintile, and the unmet need is larger among poorer women. Hospital deliveries to poorer women have higher proportions of AMIs, most likely because of the low rates of facility deliveries in this group. Combining clinical and survey data is a powerful approach to measuring disparities in access to obstetric surgery.